St Helena Parish CU -- Secure Loan Application Form

Individual Credit: You must complete the Applicant section about yourself and the Other section about your spouse if:

1. You live in or the property pledged as collateral is located in a community property state (AK, AZ, CA, ID, LA, NM, NV, TX, WA, WI),

2. Your spouse will use the account, or

3. You are relying on your spouse's income as a basis for repayment. If you are relying on income from alimony, child support, or separate maintenance, complete the Other section to the extent possible about the person on whose payments you are relying.

Joint Credit: Each Applicant must individually complete the appropriate section below, If Co-Borrower is spouse of the Applicant,- mark the Co-Applicant box.

Check below to indicate the type of credit for which you are applying.

This credit union may offer Life / Disability, GAP or Warranty Insurance, but none is required to obtain credit. If you notify the credit union that you are interested, the credit union will disclose the cost of the voluntary coverage to you. You must sign a separate election disclosing the terms and conditions for any coverage to become effective.

Email Address Purpose

Amount Requested

Account / Loan:

Individual

Joint

Repayment:

Cash/Check Automatic Payment

Year Make Model Mileage

Sales Price $

VIN #

Year Make Model VIN # Mileage

Sales Price $

Year Make Model VIN # Mileage

Sales Price $

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Options:

Leather Seats Sun Roof 4 Wheel Drive Navigation Tow Package

Color of Vehicle: Other Options: Seller: Sales Person: Phone Number:

Check coverage(s) desired. The Credit Union will disclose the cost of this voluntary insurance to you. A separate enrolment form which discloses the terms and conditions must be signed for coverage to become effective.

Single Credit Disability Joint Credit Disability None

Single Credit Life Insurance Joint Credit Life Insurance None

Applicant's Name

Current Account Holder

Yes No

Account # Drivers License # Social Security #

US Citizen

Yes No

Birthdate Marital Status Home Phone # Mobile Phone # Address Line 1 Address Line 2 (Apt/Unit #) City State Zip Current Address Since If less than 1 year, enter previous address

Joint Name

Current Account Holder

Yes No

Account # Drivers License # Social Security #

US Citizen

Yes No

Birthdate Marital Status Home Phone # Mobile Phone # Address Line 1 Address Line 2 (Apt/Unit #) City State Zip Current Address Since If less than 1 year, enter previous address

Employer Name Employer Phone # Employer Address Department Supervisor Position Date Hired(MM/DD/YY) Monthly Gross Income ($) Other Monthly Income ($)

If at current employer less than 2 years, enter previous

Previous Employer Name Yrs Employed

Co-Applicant Employer Name Employer Phone # Employer Address Department Supervisor Position Date Hired(MM/DD/YY) Monthly Gross Income ($) Other Monthly Income ($)

If at current employer less than 2 years, enter previous

Previous Employer Name Yrs Employed

NOTE: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered as a basis for this credit request.

Enter your Rent or Mortgage

Lender Type Balance Payment

Enter your Debts and Assets

Lender Type Balance Payment

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Child Support Payments / Alimony

Applicant

Have you any outstanding judgements or past due obligations? Have you ever filed bankruptcy or debt adjustment plan confirmed under chapter 13? Have you had Property foreclosed upon or repossessed in the last 7 years? Are you a party in lawsuit? Are you other than a U.S. citizen or permanent resident alien? Is your income likely to decline in the next 2 years? Are you a co-maker, co-signer, or guarantor or any loan not listed above?

Co-Applicant

If yes to any of the above questions, please explain.

Full Name Suffix Home Phone #

What is their home address?

Street City State Zip

Relationship

Full Name Suffix Home Phone #

What is their home address?

Street City State Zip

Relationship

Notices

I/we certify that this information on all pages had been supplied truthfully, accurately and voluntarily, and therefore authorize this credit union to investigate our creditworthiness, credit history and financial responsibility through any credit bureau or by any other reasonable means for consideration for the loan applied for herein, or for any other service offered by this credit union or its affiliate. The credit union may release information about its credit experience with me/us as permitted by law. If this application is for the purpose of encumbering real property, I/we agree to pay all allowable expenses incurred in processing this application whether or not the loan is approved. This application does not constitute a contract for the extension of credit. I/we understand that it may be a Federal Crime punishable by fine or imprisonment or both knowingly make any false statements concerning any of the above facts, as applicable under the provisions of Title 18, United States Code, Section 1014.